Facility Evaluation Report

On 12/19/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding Complaint Control Number 11-AS-20250722112818. The department observed deficiencies during the course of the investigation and delivered deficiencies to the Executive Director, Jennifer Rivas .

The following deficiencies were observed:

· Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. Interviews with staff and witnesses confirmed that the facility has improperly discarded injection needles.

· On 08/22/2025 and 12/12/2025 one glucometer was observed in the medication room; according to staff and witnesses (on both days) one glucometer is used for all residents who require glucose testing. On 12/12/2025, LPA requested to view extra glucometers but medication room staff was unable to show LPA extra glucometers; staff did not know if the facility had extra glucometers.

· Interviews with staff and witnesses on 08/22/2025 and 12/12/2025 in the medication room confirmed that the facility uses one glucometer for all the residents who require glucose testing.